These are cases where an organisation's published response to a coroner stated an action, and a later coroner then raised the same or a closely related concern with it.
It shows that the concern recurred, not why. It is not a finding that the action was not taken. Newest later report first.
563 links
Earlier report
“My concern here Is that handover delays are impacting upon response times in respect of patients requiring emergency treatment &/or conveyance to hospital.”
The response stated
“have been strengthened, with the Division of Urgent Care now assuming full responsibility for the Corporate Site management team to ensure a full and co-ordinated focus is maintained on safe patient flow and ambulance handover delays. Other”
Raised again
2 years 7 months later
“Significant handover delays 1. The court noted that the NHS national target is for ambulances to handover patients to hospital is within 15 minutes of arrival.”
Both reports identify ambulance handover delays as prolonging patient wait times for emergency treatment or conveyance to hospital. They describe the same mechanism—excessive handover times reducing ambulance availability and increasing mortality risk.
Earlier report
“I am concerned that these continuing delays for ambulances at hospital handovers reflects a risk of deaths into the future.”
The response stated
“the Health Secretary has ordered a full and independent investigation into NHS performance to provide a frank assessment of the issues and challenges it faces”
Raised again
1 year 11 months later
“These handover delays lead to the unavailability of ambulances to respond to emergency calls. Furthermore, the average handover delays conceal spikes such as that which led to the long delay in this case.”
Both reports identify ambulance handover delays at emergency departments as a safety issue. They link these delays to reduced ambulance availability and increased risk of patient mortality.
Earlier report
“Significant handover delays leading to ambulance resources being tied up at hospital with increased risk in mortality for patients in the community waiting for emergency ambulances”
The response stated
“The NHS planning guidance also includes an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026 and increasing the proportion of patients admitted, discharged, and transferred from an emergency department within 12 hours across 2025/26 compared to 2024/25.”
Stated timescale: March 2026
Raised again
1 year 2 months later
“Significant handover delays”
Same coroner as the earlier report.
Both reports highlight significant ambulance handover delays at the hospital causing ambulances to be unavailable and increasing mortality risk.
Earlier report
“Continuing average handover delays (and therefore response delays) which create a risk of future deaths. The averages conceal spikes of delayed handover and ambulance response times which increase the risk of mortality.”
The response stated
“developing local partnership working between the NHS and social care and making sure people get the right support from health and social care services to return home as soon as possible”
Raised again
1 year 8 months later
“These handover delays lead to the unavailability of ambulances to respond to emergency calls. Furthermore, the average handover delays conceal spikes such as that which led to the long delay in this case.”
Same coroner as the earlier report.
Both reports identify prolonged ambulance handover delays as a hazard that increases mortality risk by reducing ambulance availability.
Tameside General Hospital · NHS body
Antibiotic prescribing without joint discussion or swallow assessmentEarlier report
“there was not a joint approach to his care and no detailed discussions regarding the decision to withhold antibiotics”
The response stated
“The joint approach to Mr [name redacted] care from both the microbiologist and the consultant physician, specifically around the decision to withhold antibiotics.”
Stated timescale: September 2024
Raised again
2 years 2 months later
“prescription of oral antibiotics without conducting a swallow assessment in a patient presenting with swallowing difficulties and lockjaw”
Both reports highlight problems with antibiotic prescribing decisions and associated documentation at Tameside General Hospital.
Staffordshire County Council · Local authority
Missing guardrails at primary crossing pointEarlier report
“heard police evidence that many pedestrians, by far the majority, when walking down Fountain Street then walked across Ball Haye Street at the 'Keep Clear' point because there was nothing to prevent them.”
The response stated
“proposed to install a short section of guardrail around the northern radius of the Fountain Street junction”
Stated timescale: 2016/17 financial year
Raised again
10 years 3 months later
“There are no pedestrian guardrails either side of the carriageway at what appears to be a primary location used by people for their speed and convenience, to avoid the need to walk further to use the pedestrian crossings”
Both reports highlight the absence of protective barriers (guardrails/railings) that leads pedestrians to take shortcuts across busy roads instead of using designated crossings. The core safety issue is the missing physical deterrent encouraging risky crossing behavior.
Essex Partnership University NHS Foundation Trust · NHS body
Inadequate risk assessment documentation and inaccurate record keepingEarlier report
“There was no evidence of any adequate formulation of risk prior to [the deceased]'s discharge from hospital on the 14 December 2022 and no evidence of any adequate risk formulation prior to [the deceased]'s discharge from the community mental health team in January 2023.”
The response stated
“The Trust have made improvements, at pace in respect of the processes for formulation of risk on discharge with the implementation of discharge steps developed by the Trust Patient Flow Team. There has also been a change in practice to ensure we hold a discharge planning meeting with the Multi-Disciplinary Team (MDT) before discharge from hospital. Clinical service managers and matrons join discharge meetings to ensure a collaborative approach.”
Stated timescale: 26th September 2024
Raised again
1 year 10 months later
“Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that: a. They had not been developed in collaboration with her and did not contain: i. Early waring signs and triggers”
Both reports highlight failures in conducting proper risk assessments and updating care plans based on patient information.
Essex Partnership University NHS Foundation Trust · NHS body
Inadequate risk assessment documentation and inaccurate record keepingEarlier report
“Multiple experienced members of the mental health teams had contact with Mrs [name redacted] between January and March and did not make detailed entries into the medical”
The response stated
“The Trust has continued to review our assessment processes to ensure that the appropriate reviews are undertaken in a timely manner and are supported through the MDT approach which then supports a joined up approach to patient assessments. Staff in the Mental Health Crisis team are required to undertake a mental health assessment for all patients, which is monitored and audited via supervision meetings and compliance reviews.”
Raised again
1 year later
“Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that:”
Same coroner as the earlier report.
Both reports highlight failures to keep risk assessments and care plans up to date and to document important clinical information.
Essex Partnership University NHS Foundation Trust · NHS body
Inadequate risk assessment documentation and inaccurate record keepingEarlier report
“Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to [the deceased]'s risk assessment consistent with Trust policy.”
The response stated
“The Trust has initiated a Record Keeping Safety Improvement Programme (SIP). Part of this includes considering how to address issues of copying and pasting.”
Raised again
1 year 2 months later
“Ms [name redacted] risk assessment and care plans had not been appropriately updated in her medical records such that:”
Both reports highlight failures to keep patients' risk assessments and care plans up‑to‑date and accurately documented.
Earlier report
“Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared.”
The response stated
“We are in the process of devising a 'Shared Care Record' with colleagues across the Integrated Care Board enabling unified access to patient records. The collaboration includes us, Essex Partnership University Trust (EPUT), Primary Care, Social Care and other key stakeholders set out below.”
Raised again
1 year 3 months later
“There was an absence of appropriate medical records recorded for Ms [name redacted] to understand her clinical presentation other than very basic information on the INR platform on INR results and medication dose.”
Same coroner as the earlier report.
Both reports highlight failures in accessing or maintaining complete patient medical records, leading to gaps in clinical understanding.
Earlier report
“Significant omissions in the medical record-keeping and some medications administered were entered into a medication chart from a previous admission in November 2023”
The response stated
“All Mid and South Essex Hospital NHS Foundation Trust ('MSE') sites have now adopted an electronic prescribing and medication administration (EPMA) platform. EPMA facilitates team members across specialties to record accurately and contemporaneously in one place. The system allows all registered users to clearly see what other medications have been administered and by whom. Staff details are visible against the record so that each interaction is name and date stamped within the patient record.”
Stated timescale: 2025
Raised again
1 year 5 months later
“There was an absence of appropriate medical records recorded for Ms [name redacted] to understand her clinical presentation”
Same coroner as the earlier report.
Both reports highlight failures in maintaining adequate and accurate medical records for patients. The earlier report notes omissions and incorrect entries from prior admissions, while the later report describes absent or insufficient records needed to understand a patient's clinical presentation.
Mid and South Essex NHS Foundation Trust · NHS body
Untrained staff conducting mental health assessmentsEarlier report
“The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm.”
The response stated
“We have therefore added a new flowchart to our 'Admission & Treatment of Patients with a Mental Health Disorder in an Acute Hospital Setting' Policy. A copy of the flowchart is attached for reference.”
Raised again
1 year 11 months later
“There were not sufficient trained staff to conduct the enhanced observations required to monitor Abbi with her known risk of severe self-harm whilst she was awaiting assessment under the Mental Health Act and actively attempting to take her own life.”
Same coroner as the earlier report.
Both reports highlight a shortage of adequately trained mental health staff to manage patients who are awaiting assessment under the Mental Health Act and are at risk of self‑harm. The earlier report focuses on the absence of specialist training for conducting mental health assessments, while the later report stresses insufficient trained personnel to provide enhanced observations during that same